Provider Demographics
NPI:1053507897
Name:ERIE V BOORMAN MD INC
Entity Type:Organization
Organization Name:ERIE V BOORMAN MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIE
Authorized Official - Middle Name:V
Authorized Official - Last Name:BOORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-481-0481
Mailing Address - Street 1:11645 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 901
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1708
Mailing Address - Country:US
Mailing Address - Phone:310-481-0481
Mailing Address - Fax:310-481-0482
Practice Address - Street 1:11645 WILSHIRE BLVD
Practice Address - Street 2:SUITE 901
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1708
Practice Address - Country:US
Practice Address - Phone:310-481-0481
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-14
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17914Medicare PIN
CAB55944Medicare UPIN